EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy

Background: Although Wernicke encephalopathy (WE) is a preventable and treatable disease it still often remains undiagnosed during life. Objectives: To create practical guidelines for diagnosis, management and prevention of the disease. Methods: We searched MEDLINE, EMBASE, LILACS, Cochrane Library. Conclusions and recommendations: The clinical diagnosis of WE should take into account the different presentations of clinical signs between alcoholics and non alcoholics (Recommendation Level C); although prevalence is higher in alcoholics, WE should be suspected in all clinical conditions which could lead to thiamine deficiency (good practice point - GPP). The clinical diagnosis of WE in alcoholics requires two of the following four signs; (i) dietary deficiencies (ii) eye signs, (iii) cerebellar dysfunction, and (iv) either an altered mental state or mild memory impairment (Level B). Total thiamine in blood sample should be measured immediately before its administration (GPP). MRI should be used to support the diagnosis of acute WE both in alcoholics and non alcoholics (Level B). Thiamine is indicated for the treatment of suspected or manifest WE. It should be given, before any carbohydrate, 200 mg thrice daily, preferably intravenously (Level C). The overall safety of thiamine is very good (Level B). After bariatric surgery we recommend follow-up of thiamine status for at least 6 months (Level B) and parenteral thiamine supplementation (GPP). Parenteral thiamine should be given to all at-risk subjects admitted to the Emergency Room (GPP). Patients dying from symptoms suggesting WE should have an autopsy (GPP).